15.8 () Palliative Care in Catastrophic disasters and humanitarian crises

Question 1

Define catastrophic disaster versus humanitarian crises

Answer 1

Catastrophic disaster: sudden, extraordinary event that causes abrupt and widespread human, material, economic, or environmental losses that overwhelm a community’s capacity to respond due to number of casualties and requires extensive external assistance

Humanitarian crises: event or series of events that critically threatens the health, safety, security, or well-being of a community or large group of people over a wide geographic area, usually with mass population displacement

Question 2

Define three types of humanitarian crises (based on causes)

Answer 2

1. Man-made crises (e.g. armed conflict, terrorism, accidents)
2. Natural disasters:
   - geophysical (earthquakes, tsunamis, volcanoes)
   - hydrological (floods, avalanche)
   - climatological (droughts)
   - meteorological (storms, cyclones)
   - biological (epidemics, plagues)
3. Complex emergencies - i.e. combination of both man made and natural disasters

Question 3

Define two major types of humanitarian crises based on timing of event

Answer 3

1. Big bang events: single incidents with immediate or sudden impact (i.e. terrorist bombings, airplane/train crahes, or industrial accidents)
2. Rising tide events: slow initial incidents but with a prolonged impact (i.e. pandemic flu, widespread ongoing exposure to chemical, biological, or nuclear agents, prolonged conflict, crisis migration)

Question 4

A. How does the impact of big bang events differ from rising tide events

B. What type of emergency response is recommended by experts?

Answer 4

A. 1. Big bang events produce large numbers of victims at outset, requiring unpredictable amount of immediate resources (but few new victims over time)

2. Rising tide events: gradual increase in the number of people affected, to catastrophic numbers, requiring more prolonged response

B. “All-hazard planning approach” so that one plan would be able to deal with any type of major incident

Question 5

List 4 groups at risk of harm or dying in crisis events

Answer 5

1. Previously healthy, now critically ill/injured and likely to die “expectant”*
2. Previous life-threatening illness, highly dependent on intensive medical care for survival
3. Those with chronic illnesses whose health deteriorate due to crisis*
4. Anyone likely to die when triaged out of curative medical care due to limited resources
5. Those requiring symptom control/supportive care while awaiting curative therapies
6. Individuals in palliative care/hospice*
7. Victims of communicable disease outbreaks with high mortality and limited treatment options
8. People in refugee camps requiring pall care during a transition through the camp*

Question 6

Define in 4 ways how vulnerability is a fluid state (rather than a fixed characteristic of a individual or group) *

Answer 6

Defined by:
- TIMING of the hazard
- the TYPE of hazard
- CIRCUMSTANCES of those affected
- degree of ACCESS to different individual, social, and community resources

Question 7

List three broad areas of focus for palliative PATIENT care under crisis circumstances

Answer 7

1. The RELIEF of pain and other symptoms and emotional suffering
2. Providing COMPASSION for the patient and their family
3. Maintenance of the patient’s DIGNITY

Question 8

What are the issues in integrating palliative care into disaster planning and humanitarian response*

Answer 8

1. Issues related to current delivery of humanitarian aid medical care
2. Alteration of medical care standards when resources are scarce
3. Application of disaster triage
4. Challenges for health care settings under crisis conditions

Question 9

What are 3 barriers to palliative care delivery in low to middle income countries?

Answer 9

1. Little to no access to opioids due to overly restrictive regulations for morphine/controlled medications
2. Lack of training and awareness of benefits of pall care among health care professionals in these countries
3. No palliative care inclusion in universal minimal standards for humanitarian response

Question 10

How does focus of medical care become altered during disasters/crisis?

Answer 10

Shift from providing the optimal highest level of care for each individual patients –> more utilitarian approach of allocation in a way that saves the largest number of lives

Question 11

Name 4 examples of altered (physician) care practices during humanitarian crises

Answer 11

1. Practicing in unfamiliar SETTINGS*
2. Providing treatment beyond their medical EXPERTISE or training*
3. Rely more on clinical JUDGEMENT than tests*
4. RATION critical care resources only to patients with best chance for long-term survival*
5. Restricting the use of ventilators to certain situations
6. Changing infection control standards to permit group isolation

Question 12

What are 4 essential elements in integrating pall care in crisis standards of care conditions

Answer 12

1. INCORPORATE pall care into disaster planning
2. TRIAGE and treatment
3. TRAINING
4. Medical SUPPLIES and equipment

Question 13

What are 4 typical categories of a disaster triage system?

What are the limitations of these systems when it comes to palliative care?

Answer 13

A1. Immediate/red: critical condition needing transport to life saving treatment

2. Urgent/yellow: Need urgent care/transport within 6 hours
3. Delayed/green: injured, need medical intervention but are stable & able to walk
4. Expectant/black: deceased or will pass within hours/days. Attempting to save would divert resources from those with survivable conditions

B. Do not recognize pall care needs (pain, suffering, dignity) of those in expectant group

Question 14

Give 3 practical examples of how palliative care can be incorporated into disaster planning

Answer 14

1. Establish min. goal for helping patients not likely to survive to die as comfortably as possible*
2. Incorporate all pall care professionals in all phases of reponse
3. Use an “all hazards approach” for delivery of pall care
4. Develop ethical protocols for how it should be delivered:
   - triggers for alternate standards
   - what levels of care
   - what settings
   - by whom
   - to whom
5. Create rapid response pall care team*
6. Develop comfort care order set*
7. Identifiy alternate care sites
8. Coordinate across instituions/regions

Question 15

What are important features of triage and treatment when delivering pall care in crisis?*

Answer 15

1. Work with first responders/locoregional planners on guidelines for crisis triage
2. What levels of care to be delivered and in which settings
3. Develop lines of authority, identify responsible personnel

Question 16

Name 3 aspects of pall care training for first responders, emergency staff, volunteers (in crisis scenarios)?

Answer 16

1. use conventional and “just in time” training techniques
2. Breaking bad news, communication, grief support, cultural competencies*
3. Symptom management*
4. Basics of patient/family counselling and peer-to-peer/provider support*
5. Training should be competency based and role-specific
6. Provide responders with self-care training